Category Archives: Suicide Assessment and Intervention

Why You Should Open with a Focus on the Negative When Using a Strength-Based Suicide Treatment Model

Keno Horse

I’m working on a book manuscript tentatively titled something like: Strength-Based Suicide Assessment and Treatment. As I do more work and professional training in this area, I’m struck by the natural dialectic involved in the whole area of suicide (I’m sure Marsha Linehan discovered this long ago).

One dialectic on my mind today involves the fact that although I’m calling the approach that I’m writing about “Strength-Based,” I often (but not always) advise clinicians to open their sessions with a focus on negative distress. The following excerpt takes a bit of content from my 7.5 hour (3-part) published video with Psychotherapy.net and explains my rationale for opening a session with a focus on negative or painful emotions. You can access the 3-part training video here: https://www.psychotherapy.net/video/suicidal-clients-series

Here’s the case example:

In the following excerpt, I’m working with Kennedy, a 15-year-old girl whose parents referred her to me for suicide ideation (see https://www.psychotherapy.net/video/suicidal-clients-series, Sommers-Flanagan, 2018). Although I might meet with her parents first, or with the whole family, in this case I chose to start therapy with her as an individual. My opening exchange with Kennedy is important because, in contrast to what you might expect from a “strength-based” approach, my focus with her is distinctly negative. Pay close attention to the italicized words and [bracketed explanation].

John:  Kennedy, thank you for meeting with me. Let me just tell you what I know, okay, because I know that you’re not exactly excited to be here. But the thing is that I know that your parents have said you’ve been talking about suicide off and on for a little while, and so they wanted me to talk with you. [I already know that suicide ideation is an issue with Kennedy, so I share that immediately. If I pretend that I don’t already know about her and her situation, it will adversely affect our rapport. This is a basic principle for working with teens, but also true for adults: Lead with a statement of what you know . . . and be clear about what you don’t know.]

And I don’t know exactly what’s happening in your life. I don’t know how you’re feeling. And I would like to be of help. And so I guess if you’re even willing to talk to me, the first thing I’d love to hear would be what’s going on in your life, and what’s making you feel bad or sad or miserable or whatever it is that you’re feeling? [You’ll notice that my opening question has a negative focus. The reason I’m starting with a question that focuses on Kennedy’s negative affect and pulls for what makes her feel bad or sad or miserable is because (a) I want to start with Kennedy’s emotional distress, because that’s what brings her to therapy, and (b) I want to immediately begin linking her emotional distress to situations or experiences that trigger her distress. By doing this, I’m focusing on the presumptive primary treatment goal (according to Shneidman) for all clients who are suicidal, and that is to reduce the perceived intolerable or excruciating emotional distress. In Kennedy’s case, one of my very first treatment targets is to reduce the frequency and intensity of whatever it is that’s triggering Kennedy’s suicide ideation. We’ll get to the positive, strength-based stuff later.]

Kennedy: I think I’m just like really busy every day. I am in volleyball, and I got a lot of homework, and I don’t get a lot of sleep. So, it’s really stressful getting up early, and my parents are always fighting, and sometimes I miss the bus, and they don’t want to drive me. So, I have to call one of my older friends to drive me, and sometimes I’m late, and I just – it’s stressful, and the teachers get mad, but it’s not my fault.

John:   Yeah. So, you’ve got some stress piling up, volleyball, school, sometimes being late, and your parents arguing. Of those, which one adds the most misery into your life? [Again, my focus is purposefully on the negative. I want to know what adds the most misery to Kennedy’s life so that I can work with her and her family or her and her school to decrease the stimulus or trigger for her misery.]

Kennedy: I think being at home is the hardest. In volleyball at least I find some joy. Like I like enjoy being on the court and playing with my team. They’re there to lift me up. But like my parents, I don’t like being at home.

John:  Okay. What do you hate about it? [When Kennedy says, “I don’t like being at home” she’s not providing me with specific information about the trigger for her distress, so I continue with that focus and stay with the negative and use a word (hate) that I think is a good match for how a teenage girl might sometimes feel about being with her family.]

Kennedy: I just – they’re always fighting. Sometimes my dad will leave, and my mom cries, and I’ll cry. And he’s just mean, and she’s mean, and they’re both mean to each other. And I just lock myself in my room.

John:   Yeah. So, even as I listen to you talk, it feels like this is a – just being around them – I don’t know what the feeling is, maybe of just being alone. Like they’re fighting, and you retreat to your room. Any other feelings coming up when that happens? [Although I’m trying to tune into specific feeling words to link to what’s happening for Kennedy, I’m also being tentative and vague and wanting to collaboratively explore the right words to use with Kennedy.]

Kennedy: I don’t know. Just sometimes I don’t feel like – I don’t feel like I have a home, or my family is not there for me, and sometimes I just don’t feel like living anymore. [Kennedy uses the term “feel like” which often is a signal that she’s talking about a cognition and not an emotion. For example, “I don’t feel like I have a home” is likely more of a cognition that leaves her with an emotion like sadness. But it’s too soon to be that emotionally nuanced with Kennedy and the important part of what she’s saying is that there’s a pattern that’s something like this: her parents’ fighting triggers a cognition, that triggers an unspecified emotion, and that triggers the cognition of “I just don’t feel like living anymore.”]

John:   Yeah. So, there are times when the family stuff feels so bad, that’s when you start to think about suicide?

Kennedy: Yeah.

Using Shneidman’s (1980) model to guide my initial interactions with Kennedy leads me to focus on her immediate emotional distress and the triggers for her distress. Exploring her distress and the triggers takes me to an early treatment plan (that will likely be revised and refined).

  1. I will focus on Kennedy’s immediate distress and collaboratively work with her on a plan to reduce her distress and create more positive affect.
  2. I will focus on specific situational variables that trigger Kennedy’s suicide ideation. Part of the treatment plan is likely to involve her parents and to try to get them to stop their intense “fighting” in her presence.
  3. As I aim toward distress reduction and reducing or eliminating the distress trigger, I will keep in mind that—like most teenagers—it may be very difficult for me to get Kennedy to agree to let me work directly with her parents on their fighting. Getting Kennedy on board for an intervention with her parents will test my therapeutic and relational skills.

While I’m working on this next book, I’ll be posting excerpts like this. As always, I would love your feedback and input on this content. Please post comments here, or email me directly at: john.sf@mso.umt.edu.

Numbers, Men and Suicide in Montana, Liz Plank, and My 42 Seconds of Fame

220px-Elizabeth_Plank

Last month in Bozeman, I took a lunch break from a 6.5 hour suicide assessment and treatment workshop for professionals, walked out of the #IwontcallitGianforte Auditorium on the campus of Montana State University where #Idonotteach, up two flights of stairs, where I met Liz Plank and the amazing video recording and production team for the Vox news show Consider It.

Despite being in the middle of a wardrobe malfunction, I was fascinatingly anxiety-free. After talking about suicide for three hours nothing else really matters much.

Liz Plank is a big deal and a fantastic dresser. All that fits fabulously with her being a fourth wave feminist and 2018 Webby award winner. I was super happy to meet her then, and now, after having met her and done a couple Tick-Tock stunts with her (watch this 9 seconds: https://www.tiktok.com/share/video/6692077388945165573?langCountry=en), I’m still super happy to have met her.

Andy Warhol said we get 15 minutes of fame and Marilyn Manson sang about 15 minutes of shame. What I got in the final Consider It episode was somewhere around 42 seconds of a mix of the two (I’m estimating here because I haven’t timed it). But here’s the good news . . . and there’s lots of good news.

  1. The Consider It episode is now available for public viewing and it’s EXCELLENT. The title: What’s Behind Montana’s Suicide Epidemic? Obviously an incredibly important topic and other than my 42 seconds of fame/shame, very thoughtfully and artfully done (first person to post a comment that accurately identifies my exact wardrobe malfunction on the Consider It site will get a free JSF book of your choice). Yes, you can watch the best ever Consider It episode right here: https://www.facebook.com/consideritshow/videos/1395971993875811/
  2. When Liz Plank got her 2018 Webby, she did a 5 word speech. Listen for her 5 words here: https://www.youtube.com/watch?v=i4pTOQ2YY5Y
  3. Wonder what the heck Liz Plank was talking about in her 5 word speech, find out here (spoiler alert, this video makes fun of Donald Trump): https://www.facebook.com/feministabulous/videos/140217433363072/
  4. If you want Liz to have John S-F back on her show to answer the question of why people vote for Trump against their own best interests, start using the hashtag, #JSFknowstheanswer EVERYWHERE and especially here: https://www.facebook.com/consideritshow/?epa=SEARCH_BOX
  5. For me to get my 15 minutes, all you have to do is watch the Consider It episode 22.5 times. https://www.facebook.com/consideritshow/videos/1395971993875811/

As always, thanks for reading and have a fabulous weekend!

John S-F

 

What Is a Strength-Based Approach to Suicide Prevention?

Sommers FB 44

Suicide—as a thought, word, or action—usually triggers fear and judgment. Even though suicidal thoughts are common and suicidal behaviors have been part of humanity from as far back as anyone can recall, to think or talk of suicide is saturated with shame and judgment. A strength-based model for suicide prevention is about shifting attitudes toward suicide from negative judgment to compassion and lovingkindness.

Most people who think about suicide are sensitive, intelligent, and self-critical. Typically, they’re judging themselves in negative ways; sometimes they experience self-hatred. All this adds up to the main proposition underlying a strength-based approach to suicide prevention: Because individuals who feel suicidal are already burying themselves in harsh judgments and negativity, what they need from others is empathy for their pain, reassurance that suicidal thoughts are a nearly universal part of human experience, compassion, help for coping with their excruciating psychological distress, and a more or less relentless focus on the positive.

No More Mental Illness and No More Moral Shaming

In 1973, Edwin Shneidman, wrote the Encyclopedia Britannica’s definition of suicide: “Suicide is not a disease (although there are those who think so); it is not, in the view of the most detached observers, an immorality.” Shneidman—often referred to as the father of suicidology (the study of suicide)—capture two harsh judgments popularly linked to suicide: Mental or moral illness. As advocates for suicide prevention, we need to doggedly follow Shneidman’s lead, and show acceptance of the mental and moral condition of people experiencing suicidality.

I like this next quotation from Nanea Hoffman. I’m not sure it fits here, but because this post is about being strength-based when thinking and talking about suicide, and this is my blog and I can include what I want, here it is:

“None of us are getting out of here alive . . . so please stop treating yourself like an afterthought. Eat the delicious food. Walk in the sunshine. Jump in the ocean. Say the truth you’re carrying in your heart like hidden treasure. Be silly. Be kind. Be weird. There’s no time for anything else.” – Nanea Hoffman

Shame surrounding suicide has a long history. By 1000 B.C. most ancient city-states had criminalized suicide. People who died from suicide were sometimes dragged through the streets to enhance their shame and possibly as deterrence for others. Around 400 A.D., Saint Augustine declared suicide an unrepentable sin. I’m not quite sure how that works because I’m guessing that Christian theology would hold up God as the authority on what’s repentable and what’s not repentable.

Contemporary suicide-related policies continue to link shame and suicide. When students die from suicide, many U.S. schools follow a “no memorializing” policy. In New Zealand, the media is prohibited from using the word suicide when reporting on suicide deaths. Most families, when struggling to write obituaries for family members who died by suicide, replace the word suicide with “died suddenly” or some other vague explanation. In an online article, Charlotte Maya wrote of the first time she was able to speak of her husband’s suicide:

“The first time I spoke publicly was about a year and a half after Sam’s death. In many ways, I think Sam would have been appalled. After all, he did not speak a word of his struggles out loud – not to a therapist, not to his friends, not to me. There is so much shame.”

Charlotte is right; there is so much shame. To avoid shame, many people, institutions, and nations have decided that—like Lord Voldemort in the Harry Potter series—suicide is the thing that must not be named.

But it should be named; if we don’t talk about it, the shame linked to suicide grows more powerful, more frightening, and less well understood. It should be named because, hundreds of thousands of people around the world are dying by suicide every year, perhaps dying in shame, perhaps dying unnecessarily, and always leaving loved ones behind who pick up on the theme of shame and begin experiencing it themselves. If we don’t talk openly about suicide, we cannot address it effectively.

Shaming people for thinking about suicide, or for making a suicide attempt, or for completing suicide, magnifies the problem. Shaming people for their suicidal thoughts only makes them less likely to speak openly about their thoughts. And, as in the case of Charlotte Maya’s husband, remaining quiet about emotional pain is linked to tragic outcomes. When people who are suicidal shutter themselves in their private worlds, the suicidal pain and distress doesn’t diminish or evaporate; instead, being alone with suicidal thoughts usually deepens hopelessness and grows desperation, both of which contribute directly to death by suicide.

Shaming individuals who are suicidal is like pouring fuel on an open fire. Suicidal people already feel immense shame. There’s no need to add more. Besides, shaming isn’t an effective deterrent. Further, as I’ll elaborate on later, suicidal thoughts aren’t primarily about death anyway. If our goal is to save lives, there’s a different and more useful emotion to link with suicide.

Instead of shame, the word suicide should evoke compassion—compassion for people who were or are so distressed that they have contemplated or completed suicide; compassion for people who lost someone they loved to suicide; compassion for ourselves, during times when we’re in psychological pain and naturally have thoughts about suicide.

I’ll be writing more about this in the future and so I’ll summarize here. What people who are suicidal need from others includes:

  • Empathy for their pain
  • Reassurance that suicidal thoughts are a nearly universal part of human experience
  • Compassion
  • Help for coping with their excruciating psychological distress
  • A more or less relentless focus on the positive (to help counter their feelings of hopelessness)

Last night I had a chance to engage in a delightful discussion of the strength-based approach with a small group of amazing people at Big Sky, Montana. Thanks to Robin and Jacque for setting that up. As a part of our time together, I flipped through a set of powerpoints. Here are the powerpoints, in case you’re interested: Big Sky Public Lecture 2019

Check out a new “Strengths-Based Suicide Assessment” continuing education course

From M 2019 Spring

This past month I worked on revising our Suicide Assessment chapter from our Clinical Interviewing (6th edition, 2017) textbook so it could function as a stand-alone continuing education course. The continuing education course is finished and now available online.

The Learning Objectives include:

Learning Objectives

This is a beginning to intermediate level course. After completing this course, you will be able to:

  • Explore your own personal reactions to suicide and identify four clinician self-care strategies.
  • Discuss and debunk four common and unhelpful myths about suicide.
  • Describe evidence-based risk/protective factors, warning signs, and cultural issues and how they can be used to deepen empathic understanding of suicidal clients.
  • Identify components of suicide theory that contribute to and guide suicide assessment.
  • Provide a comprehensive suicide assessment interview based on a social constructionist model.
  • Engage in decision-making with suicidal clients.

If you’re interested, here’s a link to the list of courses on ContinuingEdCourses.Net, with the Suicide Assessment course at the top of the list: http://www.continuingedcourses.net/active/courses/courses.php

And here’s a link that takes you deeper . . . all the way to the brand new 3 hour course, go here (I think you can read it for free and only have to pay to take the quiz and get CE credits): Suicide Assessment For Clinicians: A Strength-Based Model

Of course, if you’re interested in a three-part (7.5 hours total) continuing education video experience, here’s your link to Psychotherapy.net: https://www.psychotherapy.net/video/suicidal-clients-series

Have a great day . . . and keep on learning!

 

Op-Ed Piece — Suicide prevention in Montana: We must do better — In today’s Bozeman Daily Chronicle

Boze Coop

It’s a short piece, but given that I’m in Bozeman tomorrow evening for a public lecture on suicide and spending the day on Friday doing a day-long suicide workshop for professionals, the timing is good.

You can read the Op-Ed piece in the Chronicle: https://www.bozemandailychronicle.com/opinions/guest_columnists/suicide-prevention-in-montana-we-must-do-better/article_0607e973-2b96-500f-93ba-bf9e85f2a7a8.html

Or you can read it right here . . .

In 1973, Edwin Shneidman, widely recognized as the father of American suicidology, was asked to provide the Encyclopedia Britannica’s definition of suicide: He wrote: Suicide is not a disease (although there are those who think so); it is not, in the view of the most detached observers, an immorality (although . . . it has often been so treated in Western and other cultures).

Shneidman’s definition captured two elements of suicide that many of us still get wrong. First, suicidality is neither abnormal nor a product of a mental disorder. At one time or another, many ordinary people think about suicide. Wishing for death is a natural human response to excruciating psychological, social, or emotional distress.

Second, suicidal thoughts or acts are not moral failings. Shneidman noted that society and religion often harshly judge and marginalize anyone who experiences suicidal thoughts and feelings. People who struggle with thoughts of suicide are already feeling immense shame. Adding more shame makes people feel worse, increases the tendency toward isolation, and serves no preventative function.

If you live in Montana, you’re probably aware that news about suicide in the U.S. and suicide in Montana is nearly always bad news. By some estimates, suicide rates have risen 60% over the past 18 years, and Montana has the highest per-capita suicide rates in the nation. Although national and local efforts at suicide prevention have proliferated, these efforts haven’t stemmed the rising tide. There are many reasons for this, some of which are sociological or political and consequently not responsive to suicide prevention programming.

But, as Shneidman emphasized, we need to stop equating suicide with mental or moral weakness. Suicide prevention and intervention efforts shaped around quick, superficial questions or influenced by pathology orientations are unlikely to succeed, and in some cases, may do harm. Compassionate, collaborative, and strength-based models constitute the best path forward for improving the effectiveness of our prevention efforts. If we want people who are in suicidal crisis to open up, talk about their pain, and seek help we must make absolutely sure that we’re communicating the following message—that suicidal thoughts are natural responses to difficult life circumstances, that opening up and talking with others will be met with compassion, not judgment, and that people who seek help from others should be respected for having the strength to reach out and be vulnerable.

To help the Bozeman community learn more about a strength-based model for suicide prevention and treatment, the Big Sky Youth Empowerment Project (BYEP) is sponsoring a free public lecture on Thursday, May 16th from 6:30pm to 8:30pm in SUB Ballroom D on the campus of Montana State University. Please join me for an evening of thinking differently about suicide—with the goal of saving lives in Montana.

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John Sommers-Flanagan is a Professor of Counselor Education at the University of Montana, a clinical psychologist, and the author of over 100 professional publications, including eight books. He has a professional resource and opinion blog at https://johnsommersflanagan.com/

 

Spending Time with the Jackson Contractor’s Group in Big Sky

Missoula-College-Exterior_Web-Op

Have you ever looked at the Jackson Contractor’s Group (JCG) website? You should, it’s filled with statements about values, integrity, company culture, and they talk about “unapologetic authenticity of each Jackson employee.” Pretty cool. Oh yeah, and there are the many astounding projects they’ve done, like the new Missoula College Building, featured above. You can check out their website here: https://jacksoncontractorgroup.com/culture/

JCG is a company that’s all about construction. Other than being an admirer of their website, why are Rita and I hanging out with them in Big Sky, Montana?

The reason is that JCG cares about its employees. They also recognize that the construction industry has one of the highest (or the highest) rate of employee suicides in the U.S., and so they invited me to their corporate retreat to talk about suicide and suicide prevention.

While preparing for tomorrow’s talk, I discovered, among other things, that the Construction Financial Management Association lists several specific employment-related risk factors, including:

  • Tough guy culture
  • High pressure environment with a potential for failure and shame
  • Physical strain and psychological trauma
  • Travel away from family and friends
  • Stressful working hours/conditions
  • Stigma – Activities
  • Access to lethal means

I’m very impressed with JCG and honored to share time with them tomorrow. For those interested, I’m pasting a link to tomorrow’s powerpoints right here: Jackson Understanding and Preventing Suicide